Healthcare Provider Details

I. General information

NPI: 1255437273
Provider Name (Legal Business Name): SUSAN H GERVASI WHCNP, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN HAYES

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10100 SE SUNNYSIDE RD
CLACKAMAS OR
97015-8970
US

IV. Provider business mailing address

13683 SE 127TH AVE
CLACKAMAS OR
97015-7302
US

V. Phone/Fax

Practice location:
  • Phone: 503-786-8435
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberOR 083042345N7
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: